Amid an epidemic of overdose deaths from prescription drugs, the North Carolina Medical Board is revising and adding to its recommendations for doctors when it comes to prescribing painkillers.

A draft statement from the board includes more detailed guidelines on how best to evaluate and treat pain, including assessing a patient’s family history of alcohol or drug abuse.

The proposal also recommends that doctors talk with patients about the best ways to dispose of medications and develop treatment agreements with patients that may include periodic drug testing.

The document is intended in part to foster more doctor-patient dialogue over treatment for pain. And it should provide doctors with a “safe harbor,” meaning following the guidelines would make them less open to charges of overprescribing or inappropriately prescribing painkillers.

Doctors say the causes and treatment of pain are complicated, and it can be especially tough for physicians who don’t regularly treat pain.

“It’s not like cholesterol where you can do a blood test and say here’s the level and how you treat it,” said Dr. Rob Fields, a family medicine doctor with Mission Medical Associates. “You very much depend on an individual’s perception of their pain to know how to guide your treatment, even if you have objective tools or scores.”

Increasingly, opiates used to treat pain are being abused. And as use of these drugs has grown, so has the number of overdose deaths.

Those deaths nationwide jumped from more than 16,800 in 1999 to more than 38,000 in 2010, according to the Centers for Disease Control and Prevention.

Of the overdose deaths in 2010, nearly 60 percent involved pharmaceutical drugs. Three out of four of those deaths involved opioids, such as oxycodone and methadone, according to the CDC.

During a legislative hearing Wednesday, state officials said in 2010, 44 percent of North Carolina accidental overdose deaths involved prescriptions that had been filled within 60 days.

The state’s Program Evaluation Division has recommended the development of statewide opioid prescribing guidelines and also requirements for continuing education as a condition of license renewal for any provider who can prescribe controlled substances. The state is also recommending other changes including improvements to the state’s controlled substance reporting system.

In North Carolina, the number of unintentional poisoning deaths has increased more than 300 percent since 1999. In 2012, more than 1,100 people died, including 31 people in Buncombe County.

“Because we’re revising the (medical board’s) position statement, it does not mean that the board has not been concerned about this all along,” said Dr. Scott Kirby, the state board’s medical director.

The board has disciplined doctors who were overprescribing or inappropriately prescribing these powerful drugs, he said. “But there is increasing evidence that excessive or inappropriate prescribing by physicians and other licensees of this board is, in part, responsible for this public health crisis,” Kirby said.

Kirby stressed, “There’s no one single cause and there’s no one single group of individuals that are responsible.”

Some people abusing the drugs are buying them illegally, some are getting them from a friend or relative. Some are stealing medications. Some are getting them directly using prescriptions.

The core of the problem is in underestimating the risk of the long term use of opioids, he said.

“This is a public health crisis,” he said. “But I think it’s also important that the needs and the viewpoint of individuals who suffer from chronic pain are also not lost in the urgency to solve a problem that is harming a lot of people, families and individuals throughout the country.”

Living with pain

Deb Casaccia, 45, of Asheville, is one of those people who fears her needs could get lost in any rush to deal with prescription drug overdose crisis.

Casaccia said she “absolutely needs” the hydrocodone that was prescribed for her pain.

She has rheumatoid arthritis and fibromyalgia, which causes fatigue and muscle and joint pain. She also suffers from back pain due to the nature of her work. Casaccia says she’s been taking hydrocodone for “probably five years.”

“I’m not worried about becoming an opiate addict. It’s just like any medicine … anything you take on a regular basis, you’re body gets accustomed to it,” she said.

At one point, she was taking hydrocodone and Opana, another opioid pain medication. She was also using a Butrans patch for pain.

Casaccia’s doctor “was prescribing all three of those, and got to a point where he felt uncomfortable prescribing such strong medicine,” she said.

The doctor referred Casaccia to a pain clinic in another county. But she said they took her off her medications and gave her an alternative that made her sick. The clinic refused to prescribe hydrocodone, Casaccia said.

Casaccia, who late last year formed a support group for people with chronic pain, said it’s becoming harder for pain patients to get prescriptions for these drugs.

“There are so many people that come in and want pain meds so they can sell them or abuse them, and that’s really unfortunate for those of us that need them,” she said. “I mean, I don’t buy or sell any of my pain management drugs. But I can tell you that a 10 milligram Vicodin, hydrocodone, goes for between $7 and $10 a pill on the streets..”

New guidance

Earlier this year, the state Medical Board tentatively adopted a draft of its new position statement that covers the use of opiates for the treatment of pain. The board is accepting comment on the position statement through May 23. The policy is posted on the board website.

The state Medical Board licenses and regulates more than 34,000 physicians and more than 5,000 physician assistants.

Earlier this year, the board reprimanded an Asheville physician and restricted his ability to prescribe controlled substances. Law enforcement officials had contacted the medical board with concerns about the doctor’s prescribing practices.

Last year, the board took 39 actions related to prescribing.

According to the draft position statement, as many as “15 to 20 percent of primary care visits result in a prescription being given for opioids.”

The draft points out that sales of opioid drugs have increased “in parallel with an increase in morbidity and mortality associated with these drugs.” At the same time, one in four patients seen “in primary care settings” suffers from pain that affects daily activity.

Balancing act

For more than a year, family nurse practitioner Carriedelle Wilson has been working with pain patients at MAHEC’s Family Health Center.

Wilson is already doing many things the medical board recommends.

“We never write prescriptions on a first visit,” she said. If someone is coming to MAHEC from another practice, Wilson obtains their records and requires a drug screening.

She co-manages patients with the primary care provider and also works with behavioral health and pharmacists.

“We don’t feel opioids are the best and only way to treat pain,” she said.

But one issue is what Medicaid will pay. Exercise may help a patient, but Medicaid will only pay for three physical therapy visits.

Evaluating and treating pain is also complicated by “psychosocial factors” that contribute to the experience of pain, according to Fields.

“It’s often related to all these other stressors and all these other life things that we have no control of as providers,” he said.

And physicians don’t always have the “best information and the best evidence” about how to treat pain correctly, he said.

A desire not just to treat disease but to ease suffering is part of the job. “It’s sort of inherent to the nature of practicing medicine,” he said.

“It’s not in our nature to be detectives,” he said. “We’re supposed to have this trusting relationship with them (patients).”

Fields described how during his first week of practice following his residency, a patient tried to call in a prescription for oxycodone and then stimulants to a pharmacy using his name.

Several years later while teaching at Mountain Area Health Education Center, Fields caught the same patient trying to do the same thing.

Some doctors have decided they simply don’t want the hassle of prescribing opiates.

“Because it is so stressful for everyone, for the providers, for staff. It often leads to really difficult exchanges when you approach someone that has misused their medication or you catch them doctor shopping and you confront a patient, it’s really difficult,” he said.

Fields believes the state board’s position statement is correct and it reflects the right way to do pain management, but it will mean more work for doctors and that may drive even more to decide they don’t want to prescribe these drugs.

It already takes more work and time to treat pain patients with these drugs.

There’s also the fear that something may go wrong if a patient misuses a drug.

“Nobody wants to have a patient die with a medication they wrote a prescription for,” Fields said.

Reporting system

The Medical Board’s revised guidelines say doctors should use information from the N.C. Controlled Substance Reporting System as part of every patient’s initial evaluation and “subsequent monitoring program.”

The system has been in place since 2007.

It is not mandatory that doctors check the system before writing a prescription. Of around 52,000 practitioners in the state, less than half — nearly 20,000 — are registered to use it.

Kirby said those prescribing the drugs get into trouble when they fail to develop a “comprehensive ongoing treatment plan.”

“Most physicians will do a good initial evaluation of a patient. ...But as time goes on, it becomes kind of routine treatment,” he said.

The need for the medications should be re-evaluated, Kirby said.

Fields said physicians want to do the right thing.

“And I think if they had help and support in how best to treat these patients, and how to get to the outcomes the board has described, I think they would do it,” he said.

That support needs to come in the form of education, newer staffing models, and “help from a chronic pain specialist to support some of our more difficult patients.”

MAHEC and Mission Medical Associates have been working on “primary care redesign.” “One of the things we are doing in that regard is coming up with evidence-based best practice for lots of various conditions and chronic pain is one of those,” Fields said.

A promising pilot program is launching in McDowell County. “It’s using evidence-based protocols developed primarily by Community Care of Western North Carolina,” he said.

That includes incorporating a social worker to provide psychotherapy for patients, standardizing pain contracts and patient agreements and standardizing protocols for urine toxicology screening.